Necrotizing soft tissue infections (NSTIs) present a rare but devasting disease process for affected patients. Timely diagnosis and management of this condition is essential for critical care providers to obtain optimal patient outcomes. Given their rarity, NSTIs are often diagnosed late in the disease process, contributing to an increase in morbidity and mortality among these patients. In this review, we discuss how to classify these infections, their risk factors, pathophysiology, clinical presentation, diagnosis, scoring systems and treatment, with an emphasis on surgical management.
PelletierJGottliebMLongBPerkinsJC. Necrotizing soft tissue infections (NSTI): Pearls and pitfalls for the emergency clinician. J Emerg Med. 2022;62(4):480‐491. doi:10.1016/j.jemermed.2021.12.012
2.
PhanHHCocanourCS. Necrotizing soft tissue infections in the intensive care unit. Crit Care Med. 2010;38(9):S460‐S468. doi:10.1097/CCM.0b013e3181ec667f
3.
BonneSKadriSS. Evaluation and management of necrotizing soft tissue infections. Infect Dis Clin North Am. 2017;31(3):497‐511. doi:10.1016/j.idc.2017.05.011
4.
HakkarainenTWKopariNMPhamTNEvansHL. Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014;51(8):344‐362. doi:10.1067/j.cpsurg.2014.06.001
5.
NaamanyEShiberSDuskin-BitanH, et al.Polymicrobial and monomicrobial necrotizing soft tissue infections: Comparison of clinical, laboratory, radiological, and pathological hallmarks and prognosis. A retrospective analysis. Trauma Surg Acute Care Open. 2021;6(1):e000745. doi:10.1136/tsaco-2021-000745
6.
StevensDLBryantAE. Necrotizing soft-tissue infections. N Engl J Med. 2017;377(23):2253‐2265. doi:10.1056/NEJMra1600673
7.
HeadleyAJ. Necrotizing soft tissue infections: A primary care review. afp. 2003;68(2):323‐328.
8.
ElliottDCKuferaJAMyersRA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg. 1996;224(5):672‐683.
9.
CasqueiroJCasqueiroJAlvesC. Infections in patients with diabetes mellitus: A review of pathogenesis. Indian J Endocrinol Metab. 2012;16(Suppl1):S27‐S36. doi:10.4103/2230-8210.94253
10.
DaveCVSchneeweissSPatornoE. Association of sodium-glucose cotransporter 2 inhibitor treatment with risk of hospitalization for fournier gangrene among men. JAMA Intern Med. 2019;179(11):1587‐1590. doi:10.1001/jamainternmed.2019.2813
11.
Bersoff-MatchaSJChamberlainCCaoCKortepeterCChongWH. Fournier gangrene associated with sodium-glucose cotransporter-2 inhibitors: A review of spontaneous postmarketing cases. Ann Intern Med. 2019;170(11):764‐769. doi:10.7326/M19-0085
DerenSClelandCMLeeHMehandruSMarkowitzM. The relationship between injection drug use risk behaviors and markers of immune activation. J Acquir Immune Defic Syndr. 2017;75(1):e8‐e12. doi:10.1097/QAI.0000000000001270
14.
BosshardtTLHendersonVJClaudeHOrganJ. Necrotizing soft-tissue infections. In: Surgical Treatment: Evidence-Based and Problem-Oriented. Zuckschwerdt; 2001. Accessed April 3, 2025. https://www.ncbi.nlm.nih.gov/books/NBK6876/.
15.
StevensDLTannerMHWinshipJ, et al.Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med. 1989;321(1):1‐7. doi:10.1056/NEJM198907063210101
16.
StevensDL. Streptococcal toxic-shock syndrome: Spectrum of disease, pathogenesis, and new concepts in treatment. Emerg Infect Dis. 1995;1(3):69‐78. doi:10.3201/eid0103.950301
17.
ChelsomJHalstensenAHagaTHøibyEA. Necrotising fasciitis due to group A streptococci in western Norway: Incidence and clinical features. Lancet. 1994;344(8930):1111‐1115. doi:10.1016/s0140-6736(94)90629-7
18.
SmolleMAHörlesbergerNMusserE, et al.Air entrapment resembling necrotising fasciitis as a frequent incident following total hip arthroplasty. Sci Rep. 2019;9(1):15766. doi:10.1038/s41598-019-52113-9
19.
WongCHKhinLWHengKSTanKCLowCO. The LRINEC (laboratory risk indicator for necrotizing fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535‐1541. doi:10.1097/01.ccm.0000129486.35458.7d
20.
HsiaoCTChangCPHuangTYChenYCFannWC. Prospective validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for necrotizing fasciitis of the extremities. PLoS One. 2020;15(1):e0227748. doi:10.1371/journal.pone.0227748
21.
KimDYIavasileAKajiAH, et al.Prospective derivation and validation of a NECROtizing soft tissue InfectionS (NECROSIS) score: An EAST multicenter trial. J Trauma Acute Care Surg.2024. doi:10.1097/TA.0000000000004374
22.
HowellECKeeleyJAKajiAH, et al.Chance to cut: Defining a negative exploration rate in patients with suspected necrotizing soft tissue infection. Trauma Surg Acute Care Open. 2019;4(1):e000264. doi:10.1136/tsaco-2018-000264
23.
BoyerAVargasFCosteF, et al.Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med. 2009;35(5):847‐853. doi:10.1007/s00134-008-1373-4
24.
TomLKWrightTJHornDLBulgerEMPhamTNKeysKA. A skin-sparing approach to the treatment of necrotizing soft-tissue infections: Thinking reconstruction at initial debridement. J Am Coll Surg.2016;222(5):e47‐e60. doi:10.1016/j.jamcollsurg.2016.01.008
25.
TomLKMaineRGWangCSParentBABulgerEMKeysKA. Comparison of traditional and skin-sparing approaches for surgical treatment of necrotizing soft-tissue infections. Surg Infect (Larchmt).2020;21(4):363‐369. doi:10.1089/sur.2019.263
26.
Al-AbedYASagriotisIElsherifMWhiteBOluwajobiOAlobaidN. Tissue-Conserving, yet radical surgery for extensive gas-forming soft tissue infections arising from perirectal abscess: Report of a case. Surg Infect (Larchmt).2012;13(5):332‐335. doi:10.1089/sur.2011.047
27.
LiLLiXXiaY, et al.Recommendation of antimicrobial dosing optimization during continuous renal replacement therapy. Front Pharmacol. 2020;11:786. doi:10.3389/fphar.2020.00786
28.
HeintzBHMatzkeGRDagerWE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy. 2009;29(5):562‐577. doi:10.1592/phco.29.5.562
29.
ArnoffGBennettWBernsJBrierM. Drug Prescribing in Renal Failure. 5th ed. American College of Physicians; 2007.
30.
GilbertDChambersHSaagMPaviaABoucherH. The Sanford Guide to Antimicrobial Therapy 2021. 51st ed. Antimicrobial Therapy; 2021.
WhiteBPSiegristEA. Increasing clindamycin resistance in group A streptococcus. Lancet Infect Dis. 2021;21(9):1208‐1209. doi:10.1016/S1473-3099(21)00456-4
33.
BabikerAWarnerSLiX, et al.Adjunctive linezolid versus clindamycin for toxin inhibition in β-lactam-treated patients with invasive group A streptococcal infections in 195 US hospitals from 2016 to 2021: A retrospective cohort study with target trial emulation. Lancet Infect Dis.2025;25(3):265‐275. doi:10.1016/S1473-3099(24)00507-3
34.
LyonsNBCohenBLO’NeilCF, et al.Short versus long antibiotic duration for necrotizing soft tissue infection: A systematic review and meta-analysis. Surg Infect (Larchmt). 2023;24(5):425‐432. doi:10.1089/sur.2023.037
35.
HornDLChanJDLiK, et al.Defining the optimal antibiotic duration in necrotizing skin and soft tissue infections: Clinical experience from a quaternary referral center. Surg Infect (Larchmt). 2023;24(8):741‐748. doi:10.1089/sur.2022.294
36.
GoddardSHashmiZBlackJJansenJGriffinRGelbardR. Evaluation of Short versus Extended Duration Antibiotic Therapy on Outcomes in Necrotizing Soft Tissue Infection (DATa-NSTI Trial). Accessed April 3, 2025. https://www.east.org/content/documents/proposal_goddard.pdf.
37.
MergoumAMRhoneARLarsonNJDriesDJBlondeauBRogersFB. A guide to the use of vasopressors and inotropes for patients in shock. J Intensive Care Med. 2025;40(7):726‐738. doi:10.1177/08850666241246230
38.
MadsenMBHjortrupPBHansenMB, et al.Immunoglobulin G for patients with necrotising soft tissue infection (INSTINCT): A randomised, blinded, placebo-controlled trial. Intensive Care Med. 2017;43(11):1585‐1593. doi:10.1007/s00134-017-4786-0
39.
HofmaennerDAWendel GarciaPDBlumMR, et al.The importance of intravenous immunoglobulin treatment in critically ill patients with necrotizing soft tissue infection: A retrospective cohort study. BMC Infect Dis. 2022;22(1):168. doi:10.1186/s12879-022-07135-6
40.
BergstenHMadsenMBBergeyF, et al.Correlation between immunoglobulin dose administered and plasma neutralization of streptococcal superantigens in patients with necrotizing soft tissue infections. Clin Infect Dis. 2020;71(7):1772‐1775. doi:10.1093/cid/ciaa022
41.
ParksTWilsonCCurtisNNorrby-TeglundASriskandanS. Polyspecific intravenous immunoglobulin in clindamycin-treated patients with streptococcal toxic shock syndrome: A systematic review and meta-analysis. Clin Infect Dis. 2018;67(9):1434–1436. doi:10.1093/cid/ciy401
42.
LinnérADarenbergJSjölinJHenriques-NormarkBNorrby-TeglundA. Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: A comparative observational study. Clin Infect Dis. 2014;59(6):851–857. doi:10.1093/cid/ciu449
43.
ToppenWChoNYSarehS, et al. Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections. PLoS One. 2024;19(3):e0300738. doi:10.1371/journal.pone.0300738
44.
ShishidoASchrankGVostalA, et al. Hyperbaric oxygen therapy for necrotizing soft tissue infections: A retrospective cohort analysis of clinical outcomes. Surg Infect (Larchmt). 2025. doi:10.1089/sur.2024.285
45.
WilkinsonDDooletteD. Hyperbaric oxygen treatment and survival from necrotizing soft tissue infection. Arch Surg. 2004;139(12):1339–1345. doi:10.1001/archsurg.139.12.1339
46.
HedetoftMMadsenMBHyldegaardO. Hyperbaric oxygen treatment in the management of necrotising soft-tissue infections: results from a Danish nationwide registry study. BMJ Open. 2023;13(2):e066117. doi:10.1136/bmjopen-2022-066117